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Higa S. Editorial to "Associations of the Fibrosis-4 index with left atrial low-voltage areas and arrhythmia recurrence after catheter ablation: Cardio-hepatic interaction in patients with atrial fibrillation". J Arrhythm 2024; 40:594-595. [PMID: 38939763 PMCID: PMC11199836 DOI: 10.1002/joa3.13065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 06/29/2024] Open
Affiliation(s)
- Satoshi Higa
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular MedicineMakiminato Central HospitalOkinawaJapan
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2
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Raposeiras-Roubín S, Parada Barcia JA, Lizancos Castro A, Noriega Caro V, Ledo Piñeiro A, González Bermúdez I, González Ferreiro R, Íñiguez-Romo A, Abu-Assi E. Liver fibrosis and outcomes of atrial fibrillation: the FIB-4 index. Clin Res Cardiol 2024; 113:313-323. [PMID: 38010520 DOI: 10.1007/s00392-023-02330-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/19/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND AIMS Liver diseases play an important role in the development and progression of atrial fibrillation (AF). The Fibrosis-4 (FIB-4) index is a non-invasive score recommended for detecting liver fibrosis. Since the association between liver fibrosis and outcomes of AF patients is still not well defined, we aim to analyze prognosis impact of FIB-4 index in those patients. METHODS A retrospective population-based cohort study was performed with 12,870 unselected patients from a single health area in Spain with AF from 2014 to 2019. Cox regression models were used to estimate the association of FIB-4 index with mortality. The association with ischemic stroke (IS), major bleeding (MB), acute myocardial infarction (AMI), and heart failure (HF) was assessed by competing risk analysis. RESULTS A total of 61.1%, 22.0%, and 16.9% were classified as low, moderate and high risk of liver fibrosis according to FIB-4 index, respectively. During a mean follow-up of 4.5 ± 1.7 years, FIB-4 index was associated with mortality (adjusted HR 1.04; 95% CI 1.01-1.06; p = 0.002), MB and HF (adjusted sHR 1.03, 95% CI 1.01-1.04; p = 0.004), but not with IS or with AMI. The association between FIB-4 and MB was only found in patients treated with vitamin K antagonists, not in patients on direct oral anticoagulants. CONCLUSIONS The FIB-4 index, a non-invasive scoring method for evaluating liver fibrosis, is independently associated with all-cause mortality, MB and HF in patients with AF, suggesting that it may be useful as a risk assessment tool to identify adverse outcomes in patients with AF.
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Affiliation(s)
- Sergio Raposeiras-Roubín
- Cardiology Department, University Hospital Álvaro Cunqueiro, Estrada de Clara Campoamor, 341, 36213, Vigo, Pontevedra, Spain.
- Instituto de Investigación Sanitaria Galicia Sur, Vigo, Spain.
- Faculty of Biomedical Engineering, Vigo University, Vigo, Spain.
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
| | - Jose Antonio Parada Barcia
- Cardiology Department, University Hospital Álvaro Cunqueiro, Estrada de Clara Campoamor, 341, 36213, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur, Vigo, Spain
| | - Andrea Lizancos Castro
- Cardiology Department, University Hospital Álvaro Cunqueiro, Estrada de Clara Campoamor, 341, 36213, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur, Vigo, Spain
| | - Vanessa Noriega Caro
- Cardiology Department, University Hospital Álvaro Cunqueiro, Estrada de Clara Campoamor, 341, 36213, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur, Vigo, Spain
| | - Ana Ledo Piñeiro
- Cardiology Department, University Hospital Álvaro Cunqueiro, Estrada de Clara Campoamor, 341, 36213, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur, Vigo, Spain
| | - Inmaculada González Bermúdez
- Cardiology Department, University Hospital Álvaro Cunqueiro, Estrada de Clara Campoamor, 341, 36213, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur, Vigo, Spain
| | - Rocío González Ferreiro
- Cardiology Department, University Hospital Álvaro Cunqueiro, Estrada de Clara Campoamor, 341, 36213, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur, Vigo, Spain
| | - Andrés Íñiguez-Romo
- Cardiology Department, University Hospital Álvaro Cunqueiro, Estrada de Clara Campoamor, 341, 36213, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur, Vigo, Spain
| | - Emad Abu-Assi
- Cardiology Department, University Hospital Álvaro Cunqueiro, Estrada de Clara Campoamor, 341, 36213, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur, Vigo, Spain
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3
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Song JJ, Jackson NJ, Shang H, Honda HM, Boulier K. Assessing Safety of Anticoagulation for Atrial Fibrillation in Patients with Cirrhosis: A Real-World Outcomes Study. J Cardiovasc Pharmacol Ther 2024; 29:10742484241256271. [PMID: 39053441 DOI: 10.1177/10742484241256271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
AIMS In patients with atrial fibrillation (AF) and stroke risk factors, randomized trials have demonstrated that anticoagulation decreases the risk of ischemic stroke. However, all trials to date have excluded patients with significant liver disease, leaving guidelines to extrapolate recommendations. We aim to evaluate the impact of anticoagulation on safety events in patients with AF and cirrhosis. METHODS AND RESULTS In this retrospective cohort study, we obtained de-identified health record data to extract anticoagulation strategy, comorbidities, prescriptions, lab values, and procedures for a cohort of patients with cirrhosis who develop AF. After selecting a propensity matched population to match patients with various anticoagulation strategies, we tracked data on outcomes for death, transfusion requirements, hospital and ICU admissions. After propensity score weighting and multivariable adjustment, anticoagulation strategy was associated with increased hospital admission count (OR = 1.74 per admission, P < .001), binary risk of hospital admission (OR = 1.54, P = .010) and risk of ICU admission (OR = 1.41, P = .047). We detected no significant differences in mortality, transfusion of blood products, or average length of stay. Direct oral anticoagulant (DOAC) prescriptions were associated with increased binary risk of hospital admission compared to warfarin prescriptions. In a third comparison, DOAC strategy alone was associated with increased hospital admission count (OR = 1.41 per admission, P < .001) and binary risk of hospital admission (OR = 1.52, P = .038) compared to no anticoagulation strategy. CONCLUSION Anticoagulation strategy in patients with cirrhosis and AF was associated with increased rate of hospital admission and ICU admission but not associated with increased risk of mortality or transfusion requirement.
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Affiliation(s)
- Justin J Song
- Department of Medicine, UCLA Medical Center, Los Angeles, USA
| | | | - Helen Shang
- Department of Medicine, UCLA Medical Center, Los Angeles, USA
| | - Henry M Honda
- Division of Cardiology, Department of Medicine, UCLA Medical Center, Los Angeles, USA
| | - Kristin Boulier
- Division of Cardiology, Department of Medicine, UCLA Medical Center, Los Angeles, USA
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4
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Møller S, Wiese S, Barløse M, Hove JD. How non-alcoholic fatty liver disease and cirrhosis affect the heart. Hepatol Int 2023; 17:1333-1349. [PMID: 37770804 DOI: 10.1007/s12072-023-10590-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023]
Abstract
Liver diseases affect the heart and the vascular system. Cardiovascular complications appear to be a leading cause of death in patients with non-alcoholic fatty liver disease (NAFLD) and cirrhosis. The predominant histological changes in the liver range from steatosis to fibrosis to cirrhosis, which can each affect the cardiovascular system differently. Patients with cirrhotic cardiomyopathy (CCM) and NAFLD are at increased risk of impaired systolic and diastolic dysfunction and for suffering major cardiovascular events. However, the pathophysiological mechanisms behind these risks differ depending on the nature of the liver disease. Accurate assessment of symptoms by contemporary diagnostic modalities is essential for identifying patients at risk, for evaluating candidates for treatment, and prior to any invasive procedures. This review explores current perspectives within this field.
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Affiliation(s)
- Søren Møller
- Department Clinical Physiology and Nuclear Medicine 260, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Copenhagen University Hospital, Kettegaards alle 30, 2650, Hvidovre, Denmark.
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Signe Wiese
- Gastro Unit, Medical Division, Hvidovre Hospital, Hvidovre, Denmark
| | - Mads Barløse
- Department Clinical Physiology and Nuclear Medicine 260, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Copenhagen University Hospital, Kettegaards alle 30, 2650, Hvidovre, Denmark
| | - Jens D Hove
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Hvidovre Hospital, Hvidovre, Denmark
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Ahmed T, Messerli AW. Double Trouble: The Challenge of Neuroprotection in Patients with Liver Cirrhosis and Atrial Fibrillation. Am J Cardiovasc Drugs 2023; 23:599-600. [PMID: 37639202 DOI: 10.1007/s40256-023-00608-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Taha Ahmed
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
| | - Adrian W Messerli
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA.
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Yusuff H, Chawla S, Sato R, Dugar S, Bangash MN, Antonini MV, Shelley B, Valchanov K, Roscoe A, Scott J, Akhtar W, Rosenberg A, Dimarakis I, Khorsandi M, Zochios V. Mechanisms of Acute Right Ventricular Injury in Cardiothoracic Surgical and Critical Care Settings: Part 2. J Cardiothorac Vasc Anesth 2023; 37:2318-2326. [PMID: 37625918 DOI: 10.1053/j.jvca.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/05/2023] [Accepted: 07/17/2023] [Indexed: 08/27/2023]
Abstract
The right ventricle (RV) is intricately linked in the clinical presentation of critical illness; however, the basis of this is not well-understood and has not been studied as extensively as the left ventricle. There has been an increased awareness of the need to understand how the RV is affected in different critical illness states. In addition, the increased use of point-of-care echocardiography in the critical care setting has allowed for earlier identification and monitoring of the RV in a patient who is critically ill. The first part of this review describes and characterizes the RV in different perioperative states. This second part of the review discusses and analyzes the complex pathophysiologic relationships between the RV and different critical care states. There is a lack of a universal RV injury definition because it represents a range of abnormal RV biomechanics and phenotypes. The term "RV injury" (RVI) has been used to describe a spectrum of presentations, which includes diastolic dysfunction (early injury), when the RV retains the ability to compensate, to RV failure (late or advanced injury). Understanding the mechanisms leading to functional 'uncoupling' between the RV and the pulmonary circulation may enable perioperative physicians, intensivists, and researchers to identify clinical phenotypes of RVI. This, consequently, may provide the opportunity to test RV-centric hypotheses and potentially individualize therapies.
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Affiliation(s)
- Hakeem Yusuff
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom.
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
| | - Mansoor N Bangash
- Liver Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, United Kingdom; Birmingham Liver Failure Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Benjamin Shelley
- Department of Cardiothoracic Anesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, United Kingdom; Anesthesia, Perioperative Medicine and Critical Care research group, University of Glasgow, Glasgow, United Kingdom
| | - Kamen Valchanov
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore
| | - Andrew Roscoe
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore; Department of Anesthesiology, Singapore General Hospital, National Heart Centre Singapore, Singapore
| | - Jeffrey Scott
- Jackson Health System / Miami Transplant Institute, Miami, FL
| | - Waqas Akhtar
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Alex Rosenberg
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Ioannis Dimarakis
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Vasileios Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
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Parikh NS, Basu E, Hwang MJ, Rosenblatt R, VanWagner LB, Lim HI, Murthy SB, Kamel H. Management of Stroke in Patients With Chronic Liver Disease: A Practical Review. Stroke 2023; 54:2461-2471. [PMID: 37417238 PMCID: PMC10527812 DOI: 10.1161/strokeaha.123.043011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Chronic liver disease (CLD) is a highly prevalent condition. There is burgeoning recognition that there are many people with subclinical liver disease that may nonetheless be clinically significant. CLD has a variety of systemic aberrations relevant to stroke, including thrombocytopenia, coagulopathy, elevated liver enzymes, and altered drug metabolism. There is a growing body of literature on the intersection of CLD and stroke. Despite this, there have been few efforts to synthesize these data, and stroke guidelines provide scant guidance on this topic. To fill this gap, this multidisciplinary review provides a contemporary overview of CLD for the vascular neurologist while appraising data regarding the impact of CLD on stroke risk, mechanisms, and outcomes. Finally, the review addresses acute and chronic treatment considerations for patients with stroke-ischemic and hemorrhagic-and CLD.
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Affiliation(s)
- Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., E.B., S.B.M., H.K.), Weill Cornell Medicine, New York, NY
| | | | - Mu Ji Hwang
- Department of Neurology, Brown University, Providence, RI (M.J.H.)
| | - Russel Rosenblatt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine (R.R.), Weill Cornell Medicine, New York, NY
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas (L.B.V.)
| | - Hana I Lim
- Division of Hematology and Oncology, Department of Internal Medicine.(H.I.L.), Weill Cornell Medicine, New York, NY
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., E.B., S.B.M., H.K.), Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., E.B., S.B.M., H.K.), Weill Cornell Medicine, New York, NY
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Arafa A, Kokubo Y, Kashima R, Matsumoto C, Koga M. Liver Enzymes and the Risk of Stroke among the General Japanese Population: A Prospective Cohort Study. Cerebrovasc Dis 2023; 53:252-260. [PMID: 37591215 DOI: 10.1159/000533654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/15/2023] [Indexed: 08/19/2023] Open
Abstract
INTRODUCTION Stroke is a major cause of morbidity and mortality. Liver enzymes, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transpeptidase (GGT), are markers of liver diseases with potential cardiovascular implications. This study aimed to investigate the prospective association between liver enzymes and stroke risk. METHODS We analyzed data from 3,379 men and 4,007 women without cardiovascular disease and registered in the Suita Study, a Japanese population-based prospective cohort study. The hazard ratios (HRs) and 95% confidence intervals (95% CIs) of stroke risk were estimated per quintiles of ALT, AST, and GGT in men and women. RESULTS Within a median follow-up period of 16.7 years, 438 incident stroke events were diagnosed. In men, compared to the second quintiles, the fifth (highest) quintiles of liver enzymes showed increased stroke risks: HRs (95% CIs) = 2.07 (1.35, 3.18) in ALT, 1.66 (1.10, 2.53) in AST, and 1.76 (1.11, 2.81) in GGT. The associations did not change with cerebral infarction risk: HRs (95% CIs) = 2.09 (1.24, 3.50) in ALT, 1.84 (1.11, 3.06) in AST, and 1.74 (1.00, 3.04) in GGT. The lowest ALT, AST, and GGT quintiles tended to show increased stroke and cerebral infarction risks, yet these associations were statistically insignificant. No such associations were shown in women. CONCLUSION Elevated ALT, AST, and GGT levels were associated with increased stroke and cerebral infarction risks among Japanese men.
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Affiliation(s)
- Ahmed Arafa
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Public Health, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Yoshihiro Kokubo
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Rena Kashima
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Cardiovascular Pathophysiology and Therapeutics, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Chisa Matsumoto
- Department of Cardiology, Center for Health Surveillance and Preventive Medicine, Tokyo Medical University Hospital, Shinjuku, Japan
| | - Masatoshi Koga
- Division of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Gîrleanu I, Trifan A, Huiban L, Muzica CM, Petrea OC, Sîngeap AM, Cojocariu C, Chiriac S, Cuciureanu T, Stafie R, Zenovia S, Stratina E, Rotaru A, Nastasa R, Sfarti C, Costache II, Stanciu C. Anticoagulation for Atrial Fibrillation in Patients with Decompensated Liver Cirrhosis: Bold and Brave? Diagnostics (Basel) 2023; 13:diagnostics13061160. [PMID: 36980468 PMCID: PMC10047341 DOI: 10.3390/diagnostics13061160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/07/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Atrial fibrillation is frequently diagnosed in patients with liver cirrhosis, especially in those with non-alcoholic steatohepatitis or alcoholic etiology. Anticoagulant treatment is recommended for thromboembolic protection in patients with atrial fibrillation. Considering the impaired coagulation balance in liver cirrhosis, predisposing patients to bleed or thrombotic events, the anticoagulant treatment is still a matter of debate. Although patients with liver cirrhosis were excluded from the pivotal studies that confirmed the efficacy and safety of the anticoagulant treatment in patients with atrial fibrillation, data from real-life cohorts demonstrated that the anticoagulant treatment in patients with liver cirrhosis could be safe. This review aimed to evaluate the recent data regarding the safety and efficacy of anticoagulant treatment in patients with decompensated liver cirrhosis. Direct oral anticoagulants are safer than warfarin in patients with compensated liver cirrhosis. In Child-Pugh class C liver cirrhosis, direct oral anticoagulants are contraindicated. New bleeding and ischemic risk scores should be developed especially for patients with liver cirrhosis, and biomarkers for bleeding complications should be implemented in clinical practice to personalize this treatment in a very difficult population represented by decompensated liver cirrhosis patients.
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Affiliation(s)
- Irina Gîrleanu
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Anca Trifan
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Laura Huiban
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Cristina Maria Muzica
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Oana Cristina Petrea
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Ana-Maria Sîngeap
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Camelia Cojocariu
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Stefan Chiriac
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Tudor Cuciureanu
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Remus Stafie
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Sebastian Zenovia
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Ermina Stratina
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Adrian Rotaru
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Robert Nastasa
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Catalin Sfarti
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
| | - Irina Iuliana Costache
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Cardiology Department, "Saint Spiridon" University Hospital, 700115 Iasi, Romania
| | - Carol Stanciu
- Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, "Saint Spiridon" University Hospital, 700111 Iasi, Romania
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Vandenberk B, Altieri MH, Liu H, Raj SR, Lee SS. Review article: diagnosis, pathophysiology and management of atrial fibrillation in cirrhosis and portal hypertension. Aliment Pharmacol Ther 2023; 57:290-303. [PMID: 36571829 DOI: 10.1111/apt.17368] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/16/2022] [Accepted: 12/08/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia and its management in cirrhosis can be challenging due to the altered hepatic metabolism of medications and increased risk of bleeding. AIMS To provide a comprehensive overview of the diagnosis, pathophysiology and management of AF in patients with cirrhosis from both a cardiology and a hepatology perspective. METHODS An extensive literature search was performed using the terms 'atrial fibrillation' and 'cirrhosis'. Guideline documents and consensus statements were explored. RESULTS The prevalence of AF in patients with cirrhosis ranges between 6.6% and 14.2%, while the incidence of new-onset AF in the post-operative period after liver transplant ranged between 6.8% and 10.2%. AF in patients with cirrhosis is associated with adverse outcomes in both pre-transplant and post-transplant settings, including an increased risk of stroke when compared to the general population. We review the pathogenesis of AF in general and in cirrhosis. This review also provides guidance on the management of AF, including the use of anticoagulation and rate versus rhythm control. In the absence of strict contraindications, all patients with cirrhosis and AF should be anticoagulated. The use of DOACs is preferred over vitamin K antagonists. In patients with a high bleeding risk, a DOAC with an approved antidote may be preferred. CONCLUSIONS Atrial fibrillation is increased in patients with cirrhosis. AF management requires careful consideration of treatment options. Since patients with cirrhosis were excluded from all major randomised clinical trials, dedicated research on the pathophysiology and management of AF in cirrhosis is needed.
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Affiliation(s)
- Bert Vandenberk
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Mario H Altieri
- Division of Gastroenterology, Hepatology and Nutrition, CHU Caen, Caen, France
| | - Hongqun Liu
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Samuel S Lee
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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11
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Dangl M, Grant JK, Vincent L, Ebner B, Maning J, Olorunfemi O, Zablah G, Sancassani R, Colombo R. The association of pre-transplant atrial fibrillation with in-hospital outcomes in patients undergoing orthotopic liver transplantation: A propensity score matching analysis. J Card Surg 2022; 37:4762-4773. [PMID: 36403274 DOI: 10.1111/jocs.17183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 09/19/2022] [Accepted: 10/22/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION In this study, we sought to evaluate the prevalence and association of pre-transplant atrial fibrillation (AF) on 30-day postoperative outcomes in patients undergoing orthotopic liver transplant (OLT). METHOD The National Inpatient Sample Database was queried from 2011 to 2017 for relevant ICD-9 and ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients who underwent OLT with AF and those without. RESULTS Among 45,357 patients who underwent OLT, women made up 35.8% of the overall population. The prevalence of AF before transplant was 2932 (6.5%) with a trend toward increasing prevalence, with an average annual change rate of 4.19%. Applying propensity score matching to control for potential confounding factors, there was no association between pre-transplant AF and in-hospital mortality in patients undergoing OLT, however there was a higher incidence of perioperative complications including: acute kidney injury, ventricular tachycardia, major bleeding, blood product transfusion, and septic shock. CONCLUSION In patients undergoing OLT, pre-transplant AF is increasing in prevalence and appears to be associated with similar in-hospital mortality but worse perioperative outcomes. Greater emphasis should be placed on AF in the preoperative cardiovascular risk stratification of patients undergoing OLT.
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Affiliation(s)
- Michael Dangl
- Department of Internal Medicine, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jelani K Grant
- Department of Medicine, Cardiovascular Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Louis Vincent
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Bertrand Ebner
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jennifer Maning
- Department of Medicine, Cardiovascular Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Odunayo Olorunfemi
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Gerardo Zablah
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rhea Sancassani
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rosario Colombo
- Department of Medicine, Cardiovascular Division, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
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12
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Suffredini G, Slowey C, Sun J, Gao WD, Choi CDW, Aziz H, Kilic A, Schena S, Lawton J, Hamilton JP, Dodd-O JM. Preoperative Liver Stiffness is Associated With Hospital Length of Stay After Cardiac Surgery. J Cardiothorac Vasc Anesth 2022; 36:4093-4099. [PMID: 35915004 DOI: 10.1053/j.jvca.2022.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Risk assessment models for cardiac surgery do not account for the degrees of liver dysfunction. Ultrasound shear-wave elastography measures liver stiffness (LSM), a quantitative measurement related to fibrosis, congestion, and inflammation. The authors hypothesized that preoperative liver stiffness would be associated with hospital length of stay after cardiac surgery. DESIGN Prospective observational study. SETTING University hospital, single center. PARTICIPANTS One hundred five adult patients undergoing nonemergent cardiac surgery. INTERVENTIONS Preoperative liver stiffness measured by ultrasound elastography. MEASUREMENTS AND MAIN RESULTS The associations were analyzed using linear mixed models, with adjustments for preoperative variables, duration of cardiopulmonary bypass, and type of surgery. Median liver stiffness was 6.4 kPa (range, 4.1-18.6 kPa). The median length of hospital stay was 6 days (range, 3-18 d). Each unit increase in liver stiffness, treated as a continuous variable, was associated with an increase of 0.32 ± 0.10 days in the hospital (p = 0.002). When treated as a categorical variable (<6 kPa, 6-9.4 kPa, and ≥9.5 kPa), LSM ≥9.5 kPa v LSM <6 kPa was associated strongly with an increase in hospital length of stay of 3.25 ± 0.87 days (p = 0.0003). CONCLUSIONS A preoperative LSM ≥9.5 kPa was associated with a significantly longer postoperative hospital length of stay. This association appeared independent of preoperative comorbidities commonly associated with coronary disease. Preoperative liver stiffness is a novel risk metric that is associated with the postoperative hospital length of stay after cardiac surgery.
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Affiliation(s)
- Giancarlo Suffredini
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesia Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Charlie Slowey
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesia Johns Hopkins University School of Medicine, Baltimore, MD
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Wei Dong Gao
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesia Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chun Dan W Choi
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore MD
| | - Hamza Aziz
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore MD
| | - Ahmet Kilic
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore MD
| | - Stefano Schena
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore MD
| | - Jennifer Lawton
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore MD
| | - James Peter Hamilton
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeffrey M Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesia Johns Hopkins University School of Medicine, Baltimore, MD
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13
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Rivas E, Sasaki K, Liang C, Wang J, Quintini C, Maheshwari K, Turan A, Fares M, Cywinski JB. New-Onset Atrial Fibrillation in Patients Undergoing Liver Transplantation: Retrospective Analysis of Risk Factors and Outcomes. J Cardiothorac Vasc Anesth 2022; 36:4100-4107. [PMID: 35999113 DOI: 10.1053/j.jvca.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/08/2022] [Accepted: 07/10/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to identify predictors of new-onset postoperative atrial fibrillation (POAF) during the initial 90 days following liver transplantation, and to assess the association between POAF in-hospital and 1-year mortality. DESIGN A retrospective cohort study. SETTING At a university hospital between 2005 and 2017. PATIENTS Adults without a history of preoperative atrial fibrillation who underwent orthotopicliver transplantation. MEASUREMENT AND MAIN RESULTS The authors assessed the univariate association between new-onset of POAF in the postoperative period and each potential factor through a logistic regression model. Moreover, they explored predictors for POAF through stepwise selection. Finally, the authors assessed the relationship between POAF and in-hospital and 1-year mortality using logistic regression models, and whether the duration of atrial fibrillation was associated with in-hospital and 1-year mortality. Among 857 patients, 89 (10.4%) developed POAF. Using only preoperative variables, pulmonary hypertension, age, Model for End-Stage Liver Disease (MELD) score, and White race were identified as the most important predictors. Model discrimination was 0.75 (95% CI: 0.69-0.80), and incorporating intraoperative variables was 0.77 (95% CI: 0.72-0.82). In-hospital mortality was observed in 7.2% (6/83) of patients with new-onset of POAF, and in 2.8% (22/768) without, with confounder-adjusted odds ratio (OR) 1.00 (97.5% CI: 0.29,3.45; p = 0.996). One-year mortality was 22.4% (20/89) in patients who developed POAF and 8.3% (64/768) in patients who did not, confounder-adjusted OR 2.64 (97.5% CI: 1.35-5.16; p = 0.001). The duration of POAF did not affect long-term postoperative mortality. CONCLUSION Preoperative, mostly unmodifiable comorbidities are important risk factors for new-onset POAF after liver transplantation. The POAF was not associated with in-hospital mortality, but with increased 1-year mortality. Once developed, the duration of POAF did not affect long-term mortality after a liver transplant.
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Affiliation(s)
- Eva Rivas
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH; Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Kazunari Sasaki
- Department of Liver Transplant, Cleveland Clinic, Cleveland, OH
| | - Chen Liang
- Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Jiayi Wang
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH
| | | | - Kamal Maheshwari
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Alparslan Turan
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Maan Fares
- Department of Cardiology, Cleveland Clinic, Cleveland, OH
| | - Jacek B Cywinski
- Department of OUTCOMES RESEARCH, Cleveland Clinic, Cleveland, OH; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH.
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14
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Wang Z, Wang Y, Luo F, Zhai Y, Li J, Chen Y, Li Q, Zhu L, Jiao S, Liu P, Zhou Y, Chen Y, Dong J, Sun Y. Impact of advanced liver fibrosis on atrial fibrillation recurrence after ablation in non-alcoholic fatty liver disease patients. Front Cardiovasc Med 2022; 9:960259. [PMID: 36277780 PMCID: PMC9583404 DOI: 10.3389/fcvm.2022.960259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
Aim Advanced liver fibrosis is independently associated with new onset of atrial fibrillation (AF). Non-invasive liver fibrosis scores are considered an effective strategy for assessing liver fibrosis. This study aimed to investigate the association between advanced liver fibrosis and AF recurrence after ablation in patients with non-alcoholic fatty liver disease (NAFLD). Materials and methods A total of 345 AF patients with NAFLD who underwent de novo ablation between 2019 and 2020 at two large hospitals in China were included in this study. AF recurrence was defined as the occurrence of atrial arrhythmia for more than 30 s by electrocardiogram or 24 h Holter monitoring after the first 3 months of ablation. Predictive values of non-alcoholic fatty liver disease fibrosis score (NFS) and Fibrosis-4 (FIB-4) scores for AF burden and recurrence after ablation were assessed. Results At the 1 year follow-up after ablation, 38.8% of patients showed recurrence. Patients with recurrence who had higher FIB-4 and NFS scores were more likely to have persistent AF and a duration of AF ≥ 3 years. In Kaplan-Meier analysis, patients with intermediate and high NFS and FIB-4 risk categories had a higher risk of AF recurrence. Compared to patients with the low risk, intermediate and high NFS, and FIB-4 risk were independently associated with AF recurrence in multivariate Cox regression analysis (high risk: NFS, hazard ratio (HR): 3.11, 95% confidence interval (CI): 1.68∼5.76, p < 0.001; FIB-4, HR: 3.91, 95% CI: 2.19∼6.98, p < 0.001; intermediate risk: NFS, HR: 1.85, 95% CI: 1.10∼3.10, p = 0.020; FIB-4, HR: 2.08, 95% CI: 1.27∼3.41, p = 0.003). Conclusion NFS and FIB-4 scores for advanced liver fibrosis are associated with AF burden. Advanced liver fibrosis is independently associated with AF recurrence following ablation. Advanced liver fibrosis might be meaningful in risk classification for patients after AF ablation.
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Affiliation(s)
- Zhe Wang
- Department of Cardiology, China-Japan Friendship Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yijia Wang
- Department of Cardiology, Beijing Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fangyuan Luo
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yafei Zhai
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiaju Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yinong Chen
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Qing Li
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Longyang Zhu
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Siqi Jiao
- Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Peng Liu
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Yifeng Zhou
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Yingwei Chen
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,*Correspondence: Yingwei Chen,
| | - Jianzeng Dong
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Department of Cardiology, Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Yihong Sun
- Department of Cardiology, China-Japan Friendship Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China,Department of Cardiology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China,Department of Cardiology, China-Japan Friendship Hospital, Beijing, China,Yihong Sun,
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15
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Liu X, Chen W, Shao W, Jiang Y, Cao Z, He W, Wu M, Chen Z, Ma J, Chen Y, Yu P, Zhang Y, Wang J. Liver fibrosis scores and atrial fibrillation incidence in heart failure with preserved ejection fraction. ESC Heart Fail 2022; 9:3985-3994. [PMID: 35996808 PMCID: PMC9773713 DOI: 10.1002/ehf2.14087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/05/2022] [Accepted: 07/14/2022] [Indexed: 01/19/2023] Open
Abstract
AIM Non-alcoholic fatty liver disease (NAFLD)-related advanced liver fibrosis (Stage 3 or 4) was reported to be linked to worse prognosis in patients with heart failure with preserved ejection fraction (HFpEF). This study aims to assess the relationship between liver fibrosis scores and new-onset atrial fibrillation (AF) incidence in patients with HFpEF in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. METHODS AND RESULTS Baseline liver fibrosis levels, assessed by NAFLD fibrosis score (NFS) or Fibrosis-4 index (FIB-4), with AF incidence were expressed as hazard ratios (HRs) using the Cox proportional hazard model. The risk for advanced fibrosis was estimated to be 21.5% (447/2072) as assessed by FIB-4 (>3.25) and 4.2% (88/2072) as assessed by NFS (>0.676) in HFpEF patients without baseline AF. After a median follow-up of 3.11 years, 106 new-onset AF cases occurred. In multivariate analysis, elevated NFS [NFS = -1.455-0.676: HR 2.44, 95% confidence interval (CI) 1.27-4.68; NFS > 0.676: HR 3.36, 95% CI 1.27-6.80; per 1 unit increase: HR 1.15, 95% CI 1.01-1.32], not FIB-4 (FIB-4 = 1.45-3.25: HR 1.02, 95% CI 0.67-1.55; FIB-4 > 3.25: HR 1.69, 95% CI 0.76-3.79; per 1 unit increase: HR 1.13, 95% CI 0.93-1.37), was associated with increased AF incidence. The NFS (C-index 0.662), not FIB-4 (C-index 0.531), had a moderate predictive ability in predicting incident AF. CONCLUSIONS Among patients with HFpEF, the risk of advanced liver fibrosis is associated with an increased incidence of new-onset AF and may be a novel predictor for new-onset AF. Additional studies are needed to confirm our results.
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Affiliation(s)
- Xiao Liu
- Department of CardiologySun Yat‐sen Memorial Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangdong Province Key Laboratory of Arrhythmia and ElectrophysiologySun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangzhou Key Laboratory of Molecular Mechanism and Translation in Major Cardiovascular DiseaseSun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Wenya Chen
- Department of CardiologySun Yat‐sen Memorial Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangdong Province Key Laboratory of Arrhythmia and ElectrophysiologySun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Wen Shao
- Department of EndocrineThe Second Affiliated Hospital of Nanchang UniversityNanchangJiangxiChina
| | - Yuan Jiang
- Department of CardiologySun Yat‐sen Memorial Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangdong Province Key Laboratory of Arrhythmia and ElectrophysiologySun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Zhengyu Cao
- Department of CardiologySun Yat‐sen Memorial Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangdong Province Key Laboratory of Arrhythmia and ElectrophysiologySun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Wanbing He
- Department of CardiologySun Yat‐sen Memorial Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangdong Province Key Laboratory of Arrhythmia and ElectrophysiologySun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Maoxiong Wu
- Department of CardiologySun Yat‐sen Memorial Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangdong Province Key Laboratory of Arrhythmia and ElectrophysiologySun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Zhiteng Chen
- Department of CardiologySun Yat‐sen Memorial Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangdong Province Key Laboratory of Arrhythmia and ElectrophysiologySun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Jianyong Ma
- Department of Pharmacology and Systems PhysiologyUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Yangxin Chen
- Department of CardiologySun Yat‐sen Memorial Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangdong Province Key Laboratory of Arrhythmia and ElectrophysiologySun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Peng Yu
- Department of EndocrineThe Second Affiliated Hospital of Nanchang UniversityNanchangJiangxiChina
| | - Yuling Zhang
- Department of CardiologySun Yat‐sen Memorial Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangdong Province Key Laboratory of Arrhythmia and ElectrophysiologySun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangzhou Key Laboratory of Molecular Mechanism and Translation in Major Cardiovascular DiseaseSun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Jingfeng Wang
- Department of CardiologySun Yat‐sen Memorial Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangdong Province Key Laboratory of Arrhythmia and ElectrophysiologySun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina,Guangzhou Key Laboratory of Molecular Mechanism and Translation in Major Cardiovascular DiseaseSun Yat‐sen Memorial Hospital, Sun Yat‐sen UniversityGuangzhouGuangdongChina
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16
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So WZ, Tan FL, Tan DJH, Ng CH, Yong JN, Syn N, Tang ASP, Wong RC, Lin W, Tan EXX, Huang DQ, Dan YY, Chew NWS, Siddiqui MS, Muthiah MD. A systematic review and meta-analysis on the impact of pre-existing and new-onset atrial fibrillation on outcomes before and after liver transplantation. Dig Liver Dis 2022; 54:614-621. [PMID: 34896025 DOI: 10.1016/j.dld.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/07/2021] [Accepted: 11/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Atrial Fibrillation (AF) is the most commonly diagnosed cardiac arrhythmia. It is associated with significant morbidity and mortality, as it is a major risk factor for cerebral vascular accidents (CVA). Our aim was to determine the prevalence of pre-existing and new-onset AF among patients undergoing liver transplantation (LT) and its impact on post-transplant outcomes. METHODS Medline and Embase were searched. Single-arm analysis was conducted using the generalized linear mixed model to determine the prevalence of pre-existing and new-onset AF. Logistic regression was performed to analyze risk factors. Comparative meta-analysis in odds ratio was conducted for binary outcomes. RESULTS Twenty articles were included, with 17 studies on pre-existing AF, and 7 including data on new-onset AF post-LT. The prevalence of pre-existing AF was 3.3% (CI 2.3-4.7) (14 studies, 45,070 patients) in pooled analysis. Significantly higher prevalence of pre-existing AF patients from North America was noted when compared to Europe (4.5%, CI 3.4-5.8 vs 1.5%, CI 0.8-2.7; p = 0.001). Body mass index (BMI), history of hypertension, diabetes, coronary artery disease (CAD), and cerebrovascular accidents (CVA) were risk factors for pre-existing AF. Pre-existing AF was significantly associated with major adverse cardiac or cerebrovascular events (MACCE) postoperatively (OR 8.02, 95%CI 5.40-11.90, p < 0.001). New-onset AF post-LT had an incidence of 6.8% (CI 4.9-9.3), and was associated with increased risk of mortality (OR 2.31, 95% CI 1.76-3.02, p < 0.001) and graft failure (OR 2.98, CI 1.99-4.47, p < 0.001). CONCLUSION AF is relatively more common among patients undergoing LT compared to the general non-transplant population. Additionally, it is associated with adverse outcomes including MACCE, thus warranting clinical attention. Thorough cardiac assessment, and close surveillance of post-operative AF may be clinically prudent.
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Affiliation(s)
- Wei Zheng So
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore
| | - Felicia Liying Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore.
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore; Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Ansel Shao Pin Tang
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore
| | - Raymond C Wong
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore; Department of Cardiology, National University Heart Center, Singapore
| | - Weiqin Lin
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore; Department of Cardiology, National University Heart Center, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Tower Block Level 10, 1E Kent Ridge Road, 119228, Singapore; National University Center for Organ Transplantation, National University Health System, Singapore
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Tower Block Level 10, 1E Kent Ridge Road, 119228, Singapore; National University Center for Organ Transplantation, National University Health System, Singapore
| | - Yock Young Dan
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Tower Block Level 10, 1E Kent Ridge Road, 119228, Singapore; National University Center for Organ Transplantation, National University Health System, Singapore
| | - Nicholas W S Chew
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore; Department of Cardiology, National University Heart Center, Singapore
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Tower Block Level 10, 1E Kent Ridge Road, 119228, Singapore; National University Center for Organ Transplantation, National University Health System, Singapore.
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17
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Han S, Park J, Hong SH, Park CS, Choi J, Chae MS. Cardiovascular manifestation of end-stage liver disease and perioperative echocardiography for liver transplantation: anesthesiologist’s view. Anesth Pain Med (Seoul) 2022; 17:132-144. [PMID: 35538654 PMCID: PMC9091670 DOI: 10.17085/apm.22132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/30/2022] [Indexed: 11/19/2022] Open
Abstract
Liver transplantation (LT) is the curative therapy for decompensated cirrhosis. However, anesthesiologists can find it challenging to manage patients undergoing LT due to the underlying pathologic conditions of patients with end-stage liver disease and the high invasiveness of the procedure, which is frequently accompanied by massive blood loss. Echocardiography is a non-invasive or semi-invasive imaging tool that provides real-time information about the structural and functional status of the heart and is considered to be able to improve outcomes by enabling accurate and detailed assessments. This article reviews the pathophysiologic changes of the heart accompanied by cirrhosis that mainly affect hemodynamics. We also present a comparative review of the diagnostic criteria for cirrhotic cardiomyopathy published by the World Congress of Gastroenterology in 2005 and the Cirrhotic Cardiomyopathy Consortium in 2019. This article discusses the conditions that could affect hemodynamic stability and postoperative outcomes, such as coronary artery disease, left ventricular outflow tract obstruction, portopulmonary hypertension, hepatopulmonary syndrome, pericardial effusion, cardiac tamponade, patent foramen ovale, and ascites. Finally, we cover a number of intraoperative factors that should be considered, including intraoperative blood loss, rapid reaccumulation of ascites, manipulation of the inferior vena cava, post-reperfusion syndrome, and adverse effects of excessive fluid infusion and transfusion. This article aimed to summarize the cardiovascular manifestations of cirrhosis that can affect hemodynamics and can be evaluated using perioperative echocardiography. We hope that this article will provide information about the hemodynamic characteristics of LT recipients and stimulate more active use of perioperative echocardiography.
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Affiliation(s)
- Sangbin Han
- Department of Emergency Medicine, Cheongyang Health Center County Hospital, Cheongyang, Korea
| | - Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Soo Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jongho Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Corresponding author Min Suk Chae, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: 82-2-2258-6150 Fax: 82-2-537-1951 E-mail:
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18
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Bezinover D, Mukhtar A, Wagener G, Wray C, Blasi A, Kronish K, Zerillo J, Tomescu D, Pustavoitau A, Gitman M, Singh A, Saner FH. Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA. Transplantation 2021; 105:2184-2200. [PMID: 33534523 DOI: 10.1097/tp.0000000000003642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient- and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive. In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA. Represents ILTS and LICAGE
| | - Ahmed Mukhtar
- Department of Anesthesia and Surgical Intensive Care, Cairo University, Almanyal, Cairo, Egypt. Represents LICAGE
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, New York, NY. Represents SATA and ILTS
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA. Represents SATA
| | - Annabel Blasi
- Department of Anesthesia, IDIBAPS (Institut d´investigació biomèdica Agustí Pi i Sunyé) Hospital Clinic, Villaroel, Barcelona, Spain. Represents LICAGE and ILTS
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA. Represents SATA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY. Represents SATA and ILTS
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care, Carol Davila University of Medicine and Pharmacy, Fundeni Clinical Institute, Bucharest, Romania. Represents LICAGE
| | - Aliaksei Pustavoitau
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, MD. Represents ILTS
| | - Marina Gitman
- Department of Anesthesiology, University of Illinois Hospital, Chicago, IL. Represents SATA and ILTS
| | - Anil Singh
- Department of Liver Transplant and GI Critical Care, Sir HN Reliance Foundation Hospital, Cirgaon, Mumbai, India. Represents ILTS
| | - Fuat H Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Essen, Germany. Represents LICAGE
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19
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Ho TC, Chen YC, Lin CC, Tai HC, Wei CY, Yeh YH, Hsu CY. Reduced Risk of Atrial Fibrillation Following Cholecystectomy: A Nationwide Population-Based Study. Front Aging Neurosci 2021; 13:706815. [PMID: 34539379 PMCID: PMC8445074 DOI: 10.3389/fnagi.2021.706815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 07/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Gallstone disease (GD) is associated with a high risk of cardiovascular disease. However, it is unknown whether GD contributes to atrial fibrillation (AF). We aimed to investigate the association between GD and AF. Methods: We performed a population-based cohort study using data from the Taiwan National Health Insurance Research Database between 2001 and 2011. A GD cohort of 230,076 patients was compared with a control cohort consisting of an equal number of patients matched for age, sex, cardiovascular and gastrointestinal comorbidities. Results: In total, 5,992 (49.8/10,000 person-years) patients with GD and 5,804 (44.5/10,000 person-years) controls developed AF. GD increased AF risk with a hazard ratio (HR) of 1.20 [95% confidence interval (CI), 1.16-1.25]. In patients with GD but without cholecystectomy, the HR of AF reached 1.57 (95% CI = 1.50-1.63). After cholecystectomy, the HR of AF significantly decreased to 0.85 (95% CI = 0.81-0.90). Among the three age groups with GD (<45, 45-64, and ≥65 years), the adjusted HRs of AF were 1.59 (95% CI = 1.08-2.33), 1.31 (95% CI = 1.18-1.45), and 1.18 (95% CI = 1.13-1.22), respectively. Compared with patients with a CHA2DS2-VASc score equal to 0, the HRs of AF risk among total cohort patients and a score equal to 1, 2, 3, and ≥ 4 were 1.28 (95% CI = 1.15-1.43), 2.26 (95% CI = 2.00-2.56), 3.81 (95% CI = 3.35-4.34), and 5.09 (95% CI = 4.42-5.87), respectively. Conclusion: This population-based longitudinal follow-up study showed that patients with GD had an increased AF risk. Moreover, cholecystectomy was related to reduced AF risk. Cardiovascular checkups may be necessary for patients with GD, especially those who are young and have other typical risk factors.
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Affiliation(s)
- Tung Ching Ho
- Department of Cardiology, Chang Hua Hospital, Changhua County, Taiwan.,Department of Bioinformatics and Medical Engineering, College of Information and Electrical Engineering, Asia University, Taichung, Taiwan
| | - Yu-Ching Chen
- Department of Bioinformatics and Medical Engineering, College of Information and Electrical Engineering, Asia University, Taichung, Taiwan
| | - Che-Chen Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Hsu-Chih Tai
- Department of Exercise and Health Promotion, College of Kinesiology and Health, Chinese Culture University, Taipei, Taiwan
| | - Cheng-Yu Wei
- Department of Exercise and Health Promotion, College of Kinesiology and Health, Chinese Culture University, Taipei, Taiwan.,Department of Neurology, Chang Bing Show Chwan Memorial Hospital, Changhua County, Taiwan
| | - Yung-Hsiang Yeh
- Digestive Disease Center, Chang Bing Show Chwan Memorial Hospital, Changhua County, Taiwan
| | - Chung Y Hsu
- Graduate Institute of Clinical Medicine Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
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20
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Luo Y, Wu B, Wu Y, Peng L, Li Z, Zhu J, Su Z, Liu J, Li S, Chong Y. Atrial fibrillation increases inpatient and 4-year all-cause mortality in critically ill patients with liver cirrhosis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1239. [PMID: 34532376 PMCID: PMC8421951 DOI: 10.21037/atm-21-3111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/22/2021] [Indexed: 12/18/2022]
Abstract
Background The association between atrial fibrillation (AF) and cirrhosis is unclear. Therefore, the aim of the present study was to determine the association between AF and short-term and 4-year mortality in critically ill patients with cirrhosis using a large database. Methods The Medical Information Mart for Intensive Care III (MIMIC III) database was used to identify patients with cirrhosis hospitalized in an intensive care unit from 2001 to 2012. Demographic and clinical data were extracted from the database. Clinical data and demographic information were collected for each patient in our study. Kaplan-Meier analysis and multivariate Cox regression models were performed to examine the relation between atrial fibrillation and in-hospital and 4-year all-cause mortality. Results A total of 1,481 patients (mean age: 58 years, 68% male) with liver cirrhosis were included in the analysis, and the prevalence of AF was 14.18%. The inpatient all-cause mortality rate was 26.6%, and patients who died in hospital had a significantly higher rate of AF (21.57% vs. 11.50%, P<0.001). Multivariate Cox regression analysis indicated that AF was significantly associated with inpatient all-cause mortality [hazard ratio (HR): 1.52, 95% confidence interval (CI): 1.19–1.95, P<0.001], and 4-year all-cause mortality (HR: 1.55, 95% CI: 1.12–2.13, P=0.008). Kaplan-Meier survival analysis showed that patients with AF had a significantly higher inpatient and 4-year all-cause mortality. Conclusions Critically ill patients with liver cirrhosis have a high rate of AF, and the presence of AF is an independent risk factor for inpatient and 4-year all-cause mortality.
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Affiliation(s)
- Yanting Luo
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bingyuan Wu
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuankai Wu
- Department of Infectious Diseases, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Long Peng
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zexiong Li
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jieming Zhu
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhongzhen Su
- Department of Ultrasound, Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Jinlai Liu
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Suhua Li
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yutian Chong
- Department of Infectious Diseases, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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21
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Shenoy A, Jarava D, Stotts MJ, Intagliata NM. Anticoagulation Management in Patients With Atrial Fibrillation and Cirrhosis. Clin Liver Dis (Hoboken) 2021; 17:277-281. [PMID: 33968389 PMCID: PMC8087924 DOI: 10.1002/cld.1048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/15/2020] [Accepted: 09/25/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Abhishek Shenoy
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineUniversity of MichiganAnn ArborMI,Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMI
| | - David Jarava
- Division of Hospital MedicineDepartment of Internal MedicineNorthwestern MedicineChicagoIL
| | - Matthew J. Stotts
- Division of Gastroenterology and HepatologyDepartment of MedicineCenter for Coagulation in Liver DiseaseUniversity of Virginia Medical CenterCharlottesvilleVA
| | - Nicolas M. Intagliata
- Division of Gastroenterology and HepatologyDepartment of MedicineCenter for Coagulation in Liver DiseaseUniversity of Virginia Medical CenterCharlottesvilleVA
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22
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Chen S, Pürerfellner H, Meyer C, Sommer P, Galindo Kiuchi M, Martinek M, Futyma P, Zanchi S, Zhu L, Schratter A, Wang J, Acou WJ, Liu S, Ling Z, Yin Y, Ouyang F, Chun JKR, Schmidt B. Anticoagulation in atrial fibrillation and liver disease: a pooled-analysis of > 20000 patients. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:336-345. [PMID: 33871577 DOI: 10.1093/ehjcvp/pvab032] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/10/2021] [Accepted: 04/14/2021] [Indexed: 01/28/2023]
Abstract
AIMS Anticoagulation for atrial-fibrillation (AF) patients with liver-disease represents a clinical dilemma. We sought to evaluate the efficacy/safety of different anticoagulation, i.e. vitamin-K-antagonist (VKA) and non-VKA oral-anticoagulants (NOACs) in such patient group. METHODS AND RESULTS This was a pooled-analysis enrolling up-to-date clinical data. Two subsets: subset A (VKA vs. Non-Anticoagulation) and subset B (NOACs vs. VKA) were pre-specified. The study outcomes were ischemic-stroke(IS)/thromboembolism(TE), major-bleeding (MB), intracranial-bleeding (ICB), gastrointestinal-bleeding (GIB) and all-cause mortality.A total of 20,042 patients' data were analyzed (subset A: N = 10275, subset B: N = 9767). Overall mean age: 71±11 years, mean CHA2DS2-VASc score: 4.0±1.8, mean HAS-BLED score: 3.6±1.2. The majority of the patients had Child-Pugh category (A-B). As compared with Non-Anticoagulation, VKA seemed to reduce the risk of IS/TE (OR: 0.60, P = 0.05), but heighten the risk of all-bleeding-events including MB (OR: 2.81, P = 0.01), ICB (OR: 1.60, P = 0.01), and GIB (OR: 3.32, P = 0.01). When compared with VKA, NOACs had similar efficacy in reducing the risk of IS/TE (OR: 0.82, P = 0.64), significantly lower risk of MB (OR: 0.54, P = 0.0003) and ICB (OR: 0.35, P < 0.0001), and trend towards reduced risk of GIB (OR: 0.72, P = 0.12) and all-cause mortality (OR: 0.79, P = 0.35). The favorable effects were maintained in subgroups of individual NOAC. CONCLUSIONS VKA appears to reduce the risk of IS/TE but increase all-bleeding-events. NOACs have similar effect in reducing the risk of IS/TE and have significantly lower risk of MB and ICB as compared with VKA. NOACs seem to be associated with better clinical outcome than VKA in patients with mild-moderate liver disease.
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Affiliation(s)
- Shaojie Chen
- Cardioangiologisches Centrum Bethanien (CCB), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany; Die Sektion Medizin, Universität zu Lübeck, Lübeck, Germany
| | - Helmut Pürerfellner
- Department für Kardiologie und Elektrophysiologie, Akademisches Lehrkrankenhaus, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Christian Meyer
- Department of Cardiology, cNEP, Cardiac Neuro- & Electrophysiology Research Group, University Heart & Vascular Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Department of Cardiology, Evangelical Hospital Düsseldorf, Düsseldorf, Germany; Heinrich-Heine-University Hospital Düsseldorf, Düsseldorf, Germany
| | - Philipp Sommer
- Klinik für Elektrophysiologie/Rhythmologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Márcio Galindo Kiuchi
- School of Medicine-Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
| | - Martin Martinek
- Department für Kardiologie und Elektrophysiologie, Akademisches Lehrkrankenhaus, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Piotr Futyma
- St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | - Simone Zanchi
- Division of Cardiology, Poliambulanza Institute Hospital Foundation, Brescia, Italy
| | - Lin Zhu
- Medizinisch-Geriatrische Klinik, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany
| | - Alexandra Schratter
- Medizinische Abteilung mit Kardiologie, Krankenhaus Hietzing Wien, Vienna, Austria
| | - Jiazhi Wang
- Intensivmedizin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Shaowen Liu
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhiyu Ling
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuehui Yin
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feifan Ouyang
- Klinik und Poliklinik für Kardiologie, Universitäres Herz und Gefäßzentrum, Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Julian K R Chun
- Cardioangiologisches Centrum Bethanien (CCB), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany; Die Sektion Medizin, Universität zu Lübeck, Lübeck, Germany
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien (CCB), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany
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23
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Koshy AN, Enyati A, Weinberg L, Han HC, Horrigan M, Gow PJ, Ko J, Thijs V, Testro A, Lim HS, Farouque O, Teh AW. Postoperative Atrial Fibrillation and Long-Term Risk of Stroke in Patients Undergoing Liver Transplantation. Stroke 2020; 52:111-120. [PMID: 33349017 DOI: 10.1161/strokeaha.120.031454] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Postoperative atrial fibrillation (POAF) is the commonest cardiovascular complication following liver transplantation (LT). This study sought to assess a possible association of POAF with subsequent thromboembolic events in patients undergoing LT. METHODS A retrospective cohort study of consecutive adults undergoing LT between 2010 and 2018 was undertaken. Patients were classified as POAF if atrial fibrillation (AF) was documented within 30 days of LT without a prior history of AF. Cases of ischemic stroke or systemic embolism were adjudicated by a panel of 2 independent physicians. RESULTS Among the 461 patients included, POAF occurred in 47 (10.2%) a median of 3 days following transplantation. Independent predictors of POAF included advancing age, postoperative sepsis and left atrial enlargement. Over a median follow-up of 4.9 (interquartile range, 2.9-7.2) years, 21 cases of stroke and systemic embolism occurred. Rates of thromboembolic events were significantly higher in patients with POAF (17.0% versus 3.1%; P<0.001). After adjustment, POAF remained a strong independent predictor of thromboembolic events (hazard ratio, 8.36 [95% CI, 2.34-29.79]). Increasing CHA2DS2VASc score was also an independent predictor of thromboembolic events (hazard ratio, 1.58 [95% CI, 1.02-2.46]). A model using POAF and a CHA2DS2VASc score ≥2 alone yielded a C statistic of 0.77, with appropriate calibration for the prediction of thromboembolic events. However, POAF was not an independent predictor of long-term mortality. CONCLUSIONS POAF following LT is associated with an 8-fold increased risk of thromboembolic events and the use of the CHA2DS2VASc score may facilitate risk stratification of these patients. Prospective studies are warranted to assess whether the use of oral anticoagulants can reduce the risk of thromboembolism following LT.
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Affiliation(s)
- Anoop N Koshy
- Department of Cardiology (A.N.K., A.E., H.-C.H., M.H., J.K., H.S.L., O.F., A.W.T.), Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia (A.N.K., L.W., H.-C.H., M.H., P.J.G., V.T., A.T., H.S.L., O.F., A.W.T.).,Victorian Liver Transplant Unit, Austin Hospital, Melbourne, Australia (A.N.K., L.W., P.J.G., A.T.)
| | - Anees Enyati
- Department of Cardiology (A.N.K., A.E., H.-C.H., M.H., J.K., H.S.L., O.F., A.W.T.), Austin Health, Melbourne, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia (L.W.), Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia (A.N.K., L.W., H.-C.H., M.H., P.J.G., V.T., A.T., H.S.L., O.F., A.W.T.).,Victorian Liver Transplant Unit, Austin Hospital, Melbourne, Australia (A.N.K., L.W., P.J.G., A.T.)
| | - Hui-Chen Han
- Department of Cardiology (A.N.K., A.E., H.-C.H., M.H., J.K., H.S.L., O.F., A.W.T.), Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia (A.N.K., L.W., H.-C.H., M.H., P.J.G., V.T., A.T., H.S.L., O.F., A.W.T.)
| | - Mark Horrigan
- Department of Cardiology (A.N.K., A.E., H.-C.H., M.H., J.K., H.S.L., O.F., A.W.T.), Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia (A.N.K., L.W., H.-C.H., M.H., P.J.G., V.T., A.T., H.S.L., O.F., A.W.T.)
| | - Paul J Gow
- The University of Melbourne, Parkville, Victoria, Australia (A.N.K., L.W., H.-C.H., M.H., P.J.G., V.T., A.T., H.S.L., O.F., A.W.T.).,Victorian Liver Transplant Unit, Austin Hospital, Melbourne, Australia (A.N.K., L.W., P.J.G., A.T.)
| | - Jefferson Ko
- Department of Cardiology (A.N.K., A.E., H.-C.H., M.H., J.K., H.S.L., O.F., A.W.T.), Austin Health, Melbourne, Victoria, Australia
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health and Department of Neurology (V.T.), Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia (A.N.K., L.W., H.-C.H., M.H., P.J.G., V.T., A.T., H.S.L., O.F., A.W.T.)
| | - Adam Testro
- The University of Melbourne, Parkville, Victoria, Australia (A.N.K., L.W., H.-C.H., M.H., P.J.G., V.T., A.T., H.S.L., O.F., A.W.T.).,Victorian Liver Transplant Unit, Austin Hospital, Melbourne, Australia (A.N.K., L.W., P.J.G., A.T.)
| | - Han S Lim
- Department of Cardiology (A.N.K., A.E., H.-C.H., M.H., J.K., H.S.L., O.F., A.W.T.), Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia (A.N.K., L.W., H.-C.H., M.H., P.J.G., V.T., A.T., H.S.L., O.F., A.W.T.)
| | - Omar Farouque
- Department of Cardiology (A.N.K., A.E., H.-C.H., M.H., J.K., H.S.L., O.F., A.W.T.), Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia (A.N.K., L.W., H.-C.H., M.H., P.J.G., V.T., A.T., H.S.L., O.F., A.W.T.)
| | - Andrew W Teh
- Department of Cardiology (A.N.K., A.E., H.-C.H., M.H., J.K., H.S.L., O.F., A.W.T.), Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia (A.N.K., L.W., H.-C.H., M.H., P.J.G., V.T., A.T., H.S.L., O.F., A.W.T.).,Cardiology Department, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia (A.W.T.)
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24
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Interplay of cardiovascular mediators, oxidative stress and inflammation in liver disease and its complications. Nat Rev Cardiol 2020; 18:117-135. [PMID: 32999450 DOI: 10.1038/s41569-020-0433-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
The liver is a crucial metabolic organ that has a key role in maintaining immune and endocrine homeostasis. Accumulating evidence suggests that chronic liver disease might promote the development of various cardiac disorders (such as arrhythmias and cardiomyopathy) and circulatory complications (including systemic, splanchnic and pulmonary complications), which can eventually culminate in clinical conditions ranging from portal and pulmonary hypertension to pulmonary, cardiac and renal failure, ascites and encephalopathy. Liver diseases can affect cardiovascular function during the early stages of disease progression. The development of cardiovascular diseases in patients with chronic liver failure is associated with increased morbidity and mortality, and cardiovascular complications can in turn affect liver function and liver disease progression. Furthermore, numerous infectious, inflammatory, metabolic and genetic diseases, as well as alcohol abuse can also influence both hepatic and cardiovascular outcomes. In this Review, we highlight how chronic liver diseases and associated cardiovascular effects can influence different organ pathologies. Furthermore, we explore the potential roles of inflammation, oxidative stress, vasoactive mediator imbalance, dysregulated endocannabinoid and autonomic nervous systems and endothelial dysfunction in mediating the complex interplay between the liver and the systemic vasculature that results in the development of the extrahepatic complications of chronic liver disease. The roles of ageing, sex, the gut microbiome and organ transplantation in this complex interplay are also discussed.
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25
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Park HE, Lee H, Choi SY, Kim HS, Chung GE. The risk of atrial fibrillation in patients with non-alcoholic fatty liver disease and a high hepatic fibrosis index. Sci Rep 2020; 10:5023. [PMID: 32193478 PMCID: PMC7081198 DOI: 10.1038/s41598-020-61750-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/02/2020] [Indexed: 12/12/2022] Open
Abstract
Previous epidemiological studies focusing on the association between liver disease and atrial fibrillation (AF) show interesting but inconsistent findings. Patients with liver disease have a higher AF risk; however, it is unknown whether the liver fibrosis index can predict AF risk. The medical records of a healthy population undergoing routine health examinations at Healthcare System Gangnam Center, Seoul National University Hospital, were reviewed retrospectively. After excluding subjects with a history of liver disease and known cardiovascular disease, 74,946 subjects with nonalcoholic fatty liver disease (NAFLD) were evaluated. The mean age was 51 ± 11 years, and 71.9% were male. AF was found in 380 (0.5%) subjects. Using univariate analyses, age, male sex, body mass index, hypertension, and diabetes were significantly associated with AF. The fibrosis 4 index (FIB 4) showed significant correlations with AF [unadjusted odds ratio (OR) 3.062 and 95% confidence interval (CI) 2.605-3.600, p = 0.000; adjusted OR 2.255 and 95% CI 1.744-2.915, p = 0.000, with cardiometabolic risk factors adjusted]. In conclusion, NAFLD subjects with higher FIB 4 were associated with increased AF risk. The noninvasive determination of liver fibrosis indices can have clinical implications on the early identification of NAFLD in patients at risk for AF.
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Affiliation(s)
- Hyo Eun Park
- Division of Cardiology, Department of Internal Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Heesun Lee
- Division of Cardiology, Department of Internal Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Su-Yeon Choi
- Division of Cardiology, Department of Internal Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Hua Sun Kim
- Division of Radiology, Department of Internal Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Goh Eun Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea.
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26
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Han H, Qin Y, Yu Y, Wei X, Guo H, Ruan Y, Cao Y, He J. Atrial fibrillation in hospitalized patients with end-stage liver disease: temporal trends in prevalence and outcomes. Liver Int 2020; 40:674-684. [PMID: 31705572 DOI: 10.1111/liv.14291] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/29/2019] [Accepted: 10/31/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS End-stage liver disease (ESLD) happens due to the development and progression of chronic liver disease. This study aims to investigate the temporal trend, patient characteristics and outcomes of atrial fibrillation (AF) in hospitalized ESLD patients across the United States. METHODS Nationwide Inpatient Sample from 2003 to 2014 was utilized to retrospectively study the weighted prevalence of AF in hospitalized ESLD patients. Multivariable regression models were used to assess the association between AF with clinical factors, in-hospital mortality, length of stay (LOS) and cost. RESULTS 639 345 hospitalizations associated with ESLD were identified, of which 47 710 (7.48%) were diagnosed with AF. The prevalence of AF increased from 5.73% in 2003 to 9.75% in 2014 in ESLD and varied by age, race, income, insurance type and hospital characteristics. Factors associated with AF included advancing age, male, white race, high income and urban teaching hospital. AF presence was associated with significant higher in-hospital mortality (odds ratio, 1.40; 95% confidence interval, 1.35-1.45), 21% longer LOS and 22% higher cost. In addition, a significant decreasing trend in in-hospital mortality was observed (from 16.70% to 10.63% in patients with AF and from 10.74% to 7.50% in patients without AF). CONCLUSIONS The prevalence of AF in hospitalized ESLD patients has continued to increase from 2003 through 2014. AF is associated with poor prognosis and higher health resource utilization. Innovative anticoagulation strategies through improved collaboration between cardiologists and hepatologists are required for better management of hospitalized ESLD patients comorbid with AF.
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Affiliation(s)
- Hedong Han
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yingyi Qin
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yamei Yu
- Department of Cardiology, Shanghai Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Wei
- Department of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Honglei Guo
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yiming Ruan
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Jia He
- Department of Health Statistics, Second Military Medical University, Shanghai, China.,Tongji University School of Medicine, Shanghai, China
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27
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Saito Y, Okumura Y, Nagashima K, Fukamachi D, Yokoyama K, Matsumoto N, Tachibana E, Kuronuma K, Oiwa K, Matsumoto M, Nishida T, Kojima T, Hanada S, Nomoto K, Sonoda K, Arima K, Takahashi F, Kotani T, Ohkubo K, Fukushima S, Itou S, Kondo K, Ando H, Ohno Y, Onikura M, Hirayama A. Impact of the Fibrosis-4 Index on Risk Stratification of Cardiovascular Events and Mortality in Patients with Atrial Fibrillation: Findings from a Japanese Multicenter Registry. J Clin Med 2020; 9:jcm9020584. [PMID: 32098093 PMCID: PMC7074173 DOI: 10.3390/jcm9020584] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 01/26/2023] Open
Abstract
Background: Liver diseases drive the development and progression of atrial fibrillation (AF). The Fibrosis-4 (FIB4) index is a non-invasive scoring method for detecting liver fibrosis, but the prognostic impact of using it for AF patients is still unknown. Herein, we evaluated using the FIB4 index as a risk assessment tool for cardiovascular events and mortality in patients with AF. Methods: We performed a post-hoc analysis of a prospective, observational multicenter study. A total of 3067 patients enrolled in a multicenter Japanese registry were grouped as first tertile (FIB4 index < 1.75, n = 1022), second tertile (1.75 ≤ FIB4 index < 2.51, n = 1022), and third tertile (FIB4 index ≥ 2.51, n = 1023). Results: The third tertile had statistically significant results: older age, lower body mass index, increased heart failure prevalence, and lower clearances of hemoglobin and creatinine (all p < 0.05). During the follow-up period, incidences of major bleeding, cardiovascular events, and all-cause mortality were significantly higher for the third tertile (all p < 0.05). After multivariate adjustment, the third tertile associated independently with cardiovascular events (HR 1.72; 95% CI 1.31–2.25) and all-cause mortality (HR 1.43; 95% CI 1.06–1.95). Adding the FIB4 index to a baseline model with CHA2DS2-VASc score improved the prediction of cardiovascular events and all-cause mortality, as shown by the significant increase in the C-statistic (all p < 0.05), net reclassification improvement (all p < 0.001), and integrated discrimination improvement (all p < 0.001). A FIB4 index ≥ 2.51 most strongly associated with cardiovascular events and all-cause mortality in AF patients with high CHADS2 scores (all p < 0.001). Conclusions: The FIB4 index is independently associated with risks of cardiovascular events and all-cause mortality in AF patients.
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Affiliation(s)
- Yuki Saito
- Division of Cardiology, Nihon University Itabashi Hospital, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
- Correspondence: ; Tel.: +81-3-3972-8111
| | - Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Koichi Nagashima
- Division of Cardiology, Nihon University Itabashi Hospital, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Daisuke Fukamachi
- Division of Cardiology, Nihon University Itabashi Hospital, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Katsuaki Yokoyama
- Department of Cardiology, Nihon University Hospital, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Naoya Matsumoto
- Department of Cardiology, Nihon University Hospital, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Eizo Tachibana
- Kawaguchi Municipal Medical Center, 180 Nishiaraijuku, Kawaguchi, Saitama 333-0833, Japan
| | - Keiichiro Kuronuma
- Kawaguchi Municipal Medical Center, 180 Nishiaraijuku, Kawaguchi, Saitama 333-0833, Japan
| | - Koji Oiwa
- Yokohama Chuo Hospital, 268 Yamashitacho, Naka-ku, Yokohama, Kanagawa 231-0023, Japan
| | - Michiaki Matsumoto
- Yokohama Chuo Hospital, 268 Yamashitacho, Naka-ku, Yokohama, Kanagawa 231-0023, Japan
| | - Toshihiko Nishida
- Yokohama Chuo Hospital, 268 Yamashitacho, Naka-ku, Yokohama, Kanagawa 231-0023, Japan
| | - Toshiaki Kojima
- Sekishindo Hospital, 25-19 Wakitahoncho, Kawagoe, Saitama 350-1123, Japan
| | - Shoji Hanada
- Asaka Medical Center, 1340-1 Mizonuma, Asaka, Saitama 351-0000, Japan
| | - Kazumiki Nomoto
- Tokyo Rinkai Hospital, 1-4-2 Rinkai-cho, Edogawa-ku, Tokyo 134-0086, Japan
| | - Kazumasa Sonoda
- Tokyo Rinkai Hospital, 1-4-2 Rinkai-cho, Edogawa-ku, Tokyo 134-0086, Japan
| | - Ken Arima
- Kasukabe Municipal Hospital, 6-7-1 Chuo, Kasukabe, Saitama 344-0067, Japan
| | | | - Tomobumi Kotani
- Makita General Hospital, 1-34-6 Omorikita, Ota-ku, Tokyo 143-0016, Japan
| | - Kimie Ohkubo
- Itabashi Medical Association Hospital, 3-12-6 Takashimadaira, Itabashi-ku, Tokyo 175-0082, Japan
| | - Seiji Fukushima
- Ukima Central Hospital, 2-21-19 Akabanekita, Kita-ku, Tokyo 115-0052, Japan
| | - Satoru Itou
- Itou Cardiovascular Clinic, 2-4 Higashisumiyoshi, Tokorozawa, Saitama 359-1124, Japan
| | - Kunio Kondo
- Kondo Clinic, 2-36-24 Shimoigusa, Suginami-ku, Tokyo 167-0022, Japan
| | - Hideyuki Ando
- Keiai Clinic, 3-10-23 Mukaihara, Itabashi-ku, Tokyo 173-0036, Japan
| | - Yasumi Ohno
- Ohno Medical Clinic, 1-36-1 Itabashi, Itabashi-ku, Tokyo 173-0004, Japan
| | - Motoyuki Onikura
- Onikura Clinic, 1-26-13 Katsutadai, Yachiyo, Chiba, 276-0023, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Nihon University Itabashi Hospital, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
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Kassel CA, Fremming BA, Brown BA, Markin NW. 2019 Clinical Update in Liver Transplantation. J Cardiothorac Vasc Anesth 2020; 35:1495-1502. [PMID: 32173208 DOI: 10.1053/j.jvca.2020.01.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/31/2020] [Indexed: 11/11/2022]
Abstract
Liver transplantation continues be the standard for treatment of end-stage liver disease, and even with recent advances in organ preservation, the anesthetic management continues to require understanding of multiple organ systems beyond the liver. Multiple factors contribute to hemodynamic changes after reperfusion of the liver graft that anesthesiologists should be aware of before unclamping. Concomitant renal dysfunction in end-stage liver disease is not uncommon, and preparation for continuous renal replacement therapy may need to be considered in certain cases. Cardiac evaluation of liver transplantation patients with an emphasis on arrhythmias, including atrial fibrillation, can help prevent both intraoperative and postoperative complications detrimental to the patient and graft. Finally, combined liver and thoracic organ transplantations may be indicated for certain disease processes that affect multiple organs. These cases require an understanding of the surgical technique and acknowledgment that some goals of the procedures may be in direct opposition to each other.
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29
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Arya S, Kumar P, Tiwari B, Belwal S, Saxena S, Abbas H. What Every Intensivist should Know about Impairment of Cardiac Function and Arrhythmias in Liver Disease Patients: A Review. Indian J Crit Care Med 2020; 24:1251-1255. [PMID: 33446981 PMCID: PMC7775933 DOI: 10.5005/jp-journals-10071-23695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objectives Impairment of cardiac function and arrhythmias often coexist in patients with liver diseases. Many studies have proved this coexistence and put forward various theories toward its pathophysiology. This narrative review tries to find the answers with supporting evidence on five main questions: Materials and methods Clinical evidence was obtained by using search engines, namely, Cochrane Library, PubMed, and Google Scholar. Studies published in journals in the English language, between January 1969 and December 2019, which mentioned the relationship between cardiac arrhythmia and liver disease, were included. We used the keywords: jaundice, bilirubin, arrhythmia, ECG, QTc interval, QT dispersion, liver, and cirrhosis. Relevant animal or human studies answering the five main questions were extracted and reviewed. Conclusion The evidence included in our review sheds light on the fact that approximately 50% of liver cirrhosis cases develop cirrhotic cardiomyopathy (CC) and there has been an association between liver abnormalities and cardiac pathology. The present review also supports that there exists a strong association between high levels of serum bilirubin levels and cardiac arrhythmias, QTc value can be relied upon as a risk factor for predicting imminent arrhythmias, and that it is associated with mortality. Its basic pathophysiology can be explained by the potential action of bile acids in prolonging the QT interval. It also causes cardiac hypertrophy and apoptosis of cardiomyocytes leading to cardiac dysfunction. How to cite this article Arya S, Kumar P, Tiwari B, Belwal S, Saxena S, Abbas H. What Every Intensivist should Know about Impairment of Cardiac Function and Arrhythmias in Liver Disease Patients: A Review. Indian J Crit Care Med 2020;24(12):1251–1255.
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Affiliation(s)
- Sanjeev Arya
- Department of Critical Care, Max Super Specialty Hospital (Previously), Dehradun, India
| | - Prashant Kumar
- Department of Critical Care, Kailash Hospital, Noida, Uttar Pradesh, India
| | - Bhuwan Tiwari
- Department of Cardiology, Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh, India
| | - Shantanu Belwal
- Department of Critical Care, Max Super Specialty Hospital, Dehradun, India
| | - Sanjay Saxena
- Department of Critical Care, Max Super Specialty Hospital, Dehradun, India
| | - Haider Abbas
- Department of ER and Critical Care, King Georges Medical University, Lucknow, Uttar Pradesh, India
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30
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Rachwan RJ, Kutkut I, Hathaway TJ, Timsina LR, Kubal CA, Lacerda MA, Ghabril MS, Bourdillon PD, Mangus RS. Postoperative Atrial Fibrillation and Flutter in Liver Transplantation: An Important Predictor of Early and Late Morbidity and Mortality. Liver Transpl 2020; 26:34-44. [PMID: 31454145 DOI: 10.1002/lt.25631] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/14/2019] [Indexed: 12/11/2022]
Abstract
Postoperative atrial fibrillation/flutter (POAF) is the most common perioperative arrhythmia and may be particularly problematic after liver transplantation (LT). This study is a single-center retrospective analysis of POAF to determine its incidence following LT, to identify risk factors, to assess its impact on clinical outcomes, and to summarize management strategies. The records of all patients who underwent LT between 2010 and 2018 were reviewed. Extracted data included pre-LT demographics and cardiac evaluation, in-hospital post-LT cardiac events, early and late complications, and survival. Among 1011 patients, the incidence of post-LT POAF was 10%. Using binary logistic regression, pre-LT history of atrial fibrillation was the strongest predictor of POAF (odds ratio [OR], 6.72; 95% confidence interval [CI], 2.00-22.57; P < 0.001), followed by history of coronary artery disease (CAD; OR, 2.52; 95% CI, 1.10-5.81; P = 0.03). Cardiac stress testing abnormality and CAD on cardiac catheterization were also associated with higher risk. Median time to POAF onset after LT was 3 days with 72% of cases resolving within 48 hours. POAF patients had greater hospital length of stay, death during the LT admission, and 90-day and 1-year mortality. POAF was an independent risk factor for post-LT mortality (OR, 2.0; 95% CI, 1.3-3.0; P < 0.01). Amiodarone was administered to 73% of POAF patients with no evidence of increased serum alanine aminotransferase levels. POAF occurred in 10% of post-LT patients with early onset and rapid resolution in most affected patients. POAF patients, however, had significant morbidity and mortality, suggesting that POAF is an important marker for worse early and late post-LT outcomes.
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Affiliation(s)
- Rayan Jo Rachwan
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Issa Kutkut
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
| | - Taylor J Hathaway
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Lava R Timsina
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Chandrashekhar A Kubal
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Marco A Lacerda
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Patrick D Bourdillon
- Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Richard S Mangus
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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31
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Izzy M, VanWagner LB, Lin G, Altieri M, Findlay JY, Oh JK, Watt KD, Lee SS. Redefining Cirrhotic Cardiomyopathy for the Modern Era. Hepatology 2020; 71:334-345. [PMID: 31342529 PMCID: PMC7288530 DOI: 10.1002/hep.30875] [Citation(s) in RCA: 189] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/09/2019] [Indexed: 12/13/2022]
Abstract
Cirrhotic cardiomyopathy (CCM) is cardiac dysfunction in patients with end-stage liver disease in the absence of prior heart disease. First defined in 2005 during the World Congress of Gastroenterology, CCM criteria consisted of echocardiographic parameters to identify subclinical cardiac dysfunction in the absence of overt structural abnormalities. Significant advancements in cardiovascular imaging over the past 14 years, including the integration of myocardial deformation imaging into routine clinical practice to identify subclinical cardiovascular dysfunction, have rendered the 2005 CCM criteria obsolete. Therefore, new criteria based on contemporary cardiovascular imaging parameters are needed. In this guidance document, assembled by a group of multidisciplinary experts in the field, new core criteria based on contemporary cardiovascular imaging parameters are proposed for the assessment of CCM. This document provides a critical assessment of the diagnosis of CCM and ongoing assessment aimed at improving clinical outcomes, particularly surrounding liver transplantation. Key points and practice-based recommendations for the diagnosis of CCM are provided to offer guidance for clinicians and identify gaps in knowledge for future investigations.
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Affiliation(s)
- Manhal Izzy
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University, Nashville, TN
| | - Lisa B. VanWagner
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Grace Lin
- Department of Cardiovascular Medicine, The Mayo Clinic, Rochester, MN
| | - Mario Altieri
- Division of Hepatology, Caen University, Caen, France
| | | | - Jae K. Oh
- Department of Cardiovascular Medicine, The Mayo Clinic, Rochester, MN
| | - Kymberly D. Watt
- Division of Gastroenterology & Hepatology, The Mayo Clinic, Rochester, MN
| | - Samuel S. Lee
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
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32
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Predictors, burden and impact of cardiac arrhythmias among patients hospitalized with end-stage liver disease. Heart Lung 2019; 49:73-79. [PMID: 31320178 DOI: 10.1016/j.hrtlng.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cirrhotic cardiomyopathy, hyperammonemia, and hepatorenal syndrome predispose to cardiac arrhythmias in End-stage liver disease (ESLD). OBJECTIVES Among ESLD hospitalizations, we evaluate the distribution and predictors of arrhythmias and their impact on hospitalization outcomes. METHODS We selected ESLD records from the Nationwide Inpatient Sample (2007-2014), identified concomitant arrhythmias (tachyarrhythmias and bradyarrhythmias), and their demographic and comorbid characteristics, and estimated the effect of arrhythmia on outcomes (SAS 9.4). RESULTS Of 57,119 ESLD hospitalizations, 6,615 had arrhythmias with higher odds with increasing age, males, jaundice, hepatorenal syndrome, alcohol use, and cardiopulmonary disorders. The most common arrhythmias were atrial fibrillation, cardiac arrest/asystole, and ventricular tachycardia. After propensity-matching (arrhythmia: no-arrhythmia, 6,609:6,609), arrhythmias were associated with 200% higher mortality, 1.7-days longer stay, $32,880 higher cost, and higher rates of shock, respiratory and kidney failures. CONCLUSIONS Due to worse outcomes with arrhythmias, there is a need for better screening and follow-up of ESLD patients for dysrhythmias.
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33
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Smith NK, Zerillo J, Schlichting N, Sakai T. Abdominal Organ Transplantation: Noteworthy Literature in 2018. Semin Cardiothorac Vasc Anesth 2019; 23:188-204. [DOI: 10.1177/1089253219842655] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A PubMed search revealed 1382 articles on pancreatic transplantation, 781 on intestinal transplantation, more than 7200 on kidney transplantation, and more than 5500 on liver transplantation published between January 1, 2018, and December 31, 2018. After narrowing the list down to human studies, 436 pancreatic, 302 intestinal, 1920 liver, and more than 2000 kidney transplantation studies were screened for inclusion in this review.
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Affiliation(s)
- Natalie K. Smith
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Jeron Zerillo
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | | | - Tetsuro Sakai
- University of Pittsburgh Medical Center Health System, PA, USA
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34
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Mantovani A, Dauriz M, Sandri D, Bonapace S, Zoppini G, Tilg H, Byrne CD, Targher G. Association between non-alcoholic fatty liver disease and risk of atrial fibrillation in adult individuals: An updated meta-analysis. Liver Int 2019; 39:758-769. [PMID: 30657626 DOI: 10.1111/liv.14044] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/03/2019] [Accepted: 01/09/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Recent studies examined the association between non-alcoholic fatty liver disease (NAFLD) and risk of atrial fibrillation (AF) in adults, but the findings have been inconsistent. We provided a quantitative estimate of the magnitude of the association between NAFLD and risk of AF. METHODS We searched publication databases using predefined keywords to identify observational studies (published up to December 14, 2018), in which NAFLD was diagnosed by biopsy, imaging or biochemistry and AF was diagnosed by medical history and electrocardiograms. Data from selected studies were extracted and meta-analysis was performed using random-effects modelling. RESULTS Nine cross-sectional and longitudinal studies were included in the final analysis (n = 364 919 individuals). Meta-analysis of data from 5 cross-sectional studies showed that NAFLD was associated with an increased risk of prevalent AF (random-effects odds ratio 2.07, 95% CI 1.38-3.10; I2 = 54.7%), independent of age, sex, body mass index, hypertension and other common AF risk factors. This risk was particularly high among patients with established diabetes (n = 1 study; random-effects odds ratio 5.17, 95% CI 2.05-13.02). Meta-analysis of data from 4 longitudinal studies showed that NAFLD was independently associated with a 10-year increased risk of incident AF only in type 2 diabetic patients (n = 1 study; random-effects hazard ratio 4.96, 95% CI 1.42-17.28). Sensitivity analyses did not modify these findings. Funnel plots did not reveal significant publication bias. CONCLUSIONS NAFLD is associated with an increased risk of AF in middle-aged and elderly individuals (especially in those with type 2 diabetes). However, the observational design of the eligible studies does not allow for proving causality.
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Affiliation(s)
- Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Marco Dauriz
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Damiano Sandri
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Stefano Bonapace
- Division of Cardiology, ''IRCCS Sacro Cuore - Don Calabria'' Hospital, Negrar (VR), Italy
| | - Giacomo Zoppini
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Hepatology & Metabolism, Medical University Innsbruck, Innsbruck, Austria
| | - Christopher D Byrne
- Nutrition and Metabolism, University of Southampton, Southampton, UK.,Southampton National Institute for Health Research Biomedical Research Centre, University Hospital Southampton, Southampton General Hospital, Southampton, UK
| | - Giovanni Targher
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
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